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        <p>嘿嘿，标题党啦。最近因为工作关系，老洁牙，以前都是洁牙师或护士洁的。看看相关的东西。<br>Esther M.Wilkins. Clinical Practice of the Dental Hygienist.2017 12th edition.<br>28章 口腔感染控制：牙刷和洁牙<br>牙科保健师有责任参考当前的研究成果，结合患者的需要为其选择合适的口腔卫生清洁方法和工具。<br>个人日常口腔护理要求每天至少进行两次下列过程：<br>①使用牙线去除邻面上的生物膜以及可能的牙间隙的食物残渣。<br>②在刷牙前使用牙线能使得牙膏中的氟或其它成分能更有效的进入牙间乳头区域，预防龋坏，促进牙龈健康。<br>③在使用牙线后，刷牙，从牙齿表面去除生物膜，并应用牙膏里的相关保护物质。<br>④最后清洁口腔及舌头。<br>牙刷的作用：<br>①去除牙菌斑生物膜。<br>②引用预防成分。<br>③控制口腔异味。<br>④清洁口腔。<br>患者选择牙刷的考虑因素：<br>①成本<br>②可用性<br>③广告宣传<br>④家庭传统<br>⑤习惯<br>现代牙刷多是合成材料（尼龙等），电动牙刷1960年代开始使用。<br>牙刷由手柄，头部和刷毛组成。刷毛的排列形状有多种多样的。要选圆钝的刷头，不能是尖的或者平的。刷牙方法，覆盖每一颗牙齿的每一个牙面，不要遗漏。用合适的压力。刷牙时间：每个位置默数5-10次，或者3-4分钟。刷牙频率：每天最少两次。鼓励睡前刷牙。使用氟化物等应该在刷牙完成之后。<br>具体刷牙方法：<br>巴氏(Bass)刷牙法过程<br>①刷毛位置<br>a.刷毛朝向根尖（上颌向上，下颌向下）<br>b.开始时刷毛与牙长轴平行<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/01.png"><br>c.从该位置，将刷毛转向牙龈缘，与牙长轴成约45°角。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/02.png"><br>d.刷毛尖部进入龈沟。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/03.png"><br>②刷牙<br>a.轻微施压使刷毛尖进入龈沟，环抱并覆盖龈缘。不要过度用力使刷毛弯曲。<br>b.用非常短促的力使刷毛前后颤动，不要使刷毛离开龈沟。<br>c.每个位置至少数10次。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/04.png"><br>③将牙刷挪到另一个位置，注意与前面的位置应该有一定的叠加。<br>④重复上面的用力方式。<br>⑤刷前牙的舌、腭侧。将牙刷竖起来，保持刷毛是直的并进入龈沟。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/05.png"><br>（其它方法略了）<br>第29章 牙间护理<br>牙龈邻间外展隙的分类<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/06.png"><br>牙线：有效使用牙线能清除邻面菌斑生物膜，减少邻接区出血。在牙龈乳头存在，没有附着丧失和根面暴露时使用牙线最有效。当附着丧失发生时，仍然可以使用牙线，但是需要更多的时间和努力。有时需要使用其它手段。<br>研究显示是否含蜡对牙线使用效果无影响。牙线的材料主要有丝线，尼龙，聚四氟乙烯等。<br>含蜡的牙线的特性：表面光滑，帮助进入邻接区；容易在牙齿间滑动，避免伤害组织；强度和耐久性。<br>不含蜡的牙线的特性：当邻接太紧的时候薄的牙线容易进入，但用力太大牙线会断；用力会通过尼龙纤维传递到牙齿表面，有更大的生物膜去除范围；太薄，要注意防止损伤牙龈组织；牙线通过清洁的牙面的声音可能为患者提供一个鼓励；没有蜡的牙线通过充填体，牙石等区域产生的粗糙摩擦可能会使患者丧失使用牙线的信心；牙线缠在手指上可能会断裂，带来不适。<br>使用牙线的时机：对大多数患者而言，刷牙前。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/07.png"><br>中指缠住牙线，示指或拇指绷住牙线，用短的拉锯样的动作将牙线缓慢放入牙间隙，将牙线贴紧牙齿，沿着龈缘以C形的方式往复运动。从最后一颗磨牙的最远端开始使用。<br>第41章 非手术牙周治疗<br>超声牙周治疗<br>1.技术原则<br>①功率设定<br>A.低功率<br>a.尽管患者很舒适，但低功力不能有效去除中等-重度牙结石。<br>b.结石可能会被抛光，从而更难以探测并去除。<br>c.残余的被抛光的牙石还含有致病物质。<br>B.中档到高功率<br>a.用合适的技术，中度到重度牙结石可以用更高的功率被去除。<br>b.可以使用局部麻醉。<br>②能量的传递<br>工作尖的全长都在震动，但只有尖端的几个毫米能传递最大的力量以去除牙石。<br>③贴合<br>a.用工作尖的侧面贴合牙面，始终使用工作尖的尖端数毫米来贴合牙面。<br>b.但在有的牙位由于牙体解剖的弯曲，直的工作尖尖端往往很难很好的贴合于牙面。<br>④洁治<br>a.需要时间将能量从工作尖传递到牙石以破坏矿化的成分。<br>b.运动的速度对于这种能量传递很关键。<br>c.以缓慢到中等的速度稳定移动工作尖。<br>2.超声洁治<br>①握持<br>a.使用改良握笔式<br>b.轻轻的握持以增加触觉敏感度。<br>c.手柄的重量倾向于拉手柄向下，给手腕增加额外的压力。解决方法：(1)将线缆缠绕在拇指和小指之间。（2）将线缆绕过医生的肩膀。<br>②支点<br>a.不需要硬组织支点（与手工洁刮治不一样），因为超声洁治并不需要手来施力。<br>b.一个轻柔的支点用来稳定和引导工作尖在前牙区段工作。<br>c.对于后牙深部区域，可以使用口外或软组织支点。<br>③贴合<br>a.保持工作尖侧面与牙面贴合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0160-toothclean/08.png"><br>b.任何时候不要将工作尖垂直的对向牙面，因为会导致牙齿损伤。<br>④洁治<br>a.保持器械工作尖以中等到慢速的速度移动，始终与牙面保持一种羽毛样的轻接触。避免刮擦或刨削牙面，局部过热，惊吓患者。<br>b.使用羽毛一样的轻压力，防止牙齿损伤。过度侧向压力会导致牙齿表面损伤，损伤工作尖，抛光牙石。<br>c.叠瓦状洁治，覆盖所有牙面，用力方向可以是水平的，垂直的或倾斜的，或它们的结合。<br>d.当器械在某个位置被困住时，停止洁治，移除工作尖，再回到那个位置，再开始洁治。<br>3.水的控制<br>①脚踏：调整好了。在评估的时候停止踩脚踏。<br>②口镜使用<br>a.水会持续喷到口镜上，影响口镜观察。<br>b.用戴着手套的手指去擦潮湿的镜面，可以使镜面变成一个清晰的潮湿的表面。当水以这样的方式被允许在口镜表面积累起来，工作区域可以通过水面清晰的被看到。(Wipe the wet sur ace o the mirror with a gloved  inger to coalesce the drops into a clear wet sur ace.  When water is allowed to pool on the sur ace in this  manner, a clearer image o the working area can be seen  through the water.临床中试一下）<br>4.手工洁治<br>清除剩余的牙石。<br>5.评估<br>用牙周探针或者不做功时的超声工作尖（无法精细检查）<br>6.问题<br>①工作尖磨损<br>使用前要检查，磨损了就换。<br>②不正确的贴合<br>a.没有将工作尖末端数毫米与牙面贴合。<br>b.牙面的解剖弯曲限制。<br>c.直的器械不能贴合弯曲的牙面。<br>d.可以用手工洁刮治器。<br>e.二者结合使用。<br>③洁治太快<br>a.移动工作尖太快了。<br>b.保持工作尖慢速的有序的移动。<br>c.工作尖的快速移动使牙石去除没有效率。<br>④不合适的覆盖<br>a.要覆盖所有牙面。<br>b.如果随机移动，就无法有效覆盖所有牙面。<br>⑤尖端压力<br>用力贴合工作尖会降低震动效率，并带来损坏。只用轻的力握持器械，但保持贴合。</p>
<p>总结：虽然是基础，还是有很多细节的。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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